Sunday, June 25, 2017

The Next Chapter

The Next Chapter

It’s not my birthday.  However, it is a new chapter.  A new chapter in my career.  I am leaving my current position and moving on to something new.  I’ve shared recently in various blog posts about creating a balance between my work and life, so it should come as no surprise.  My previous job prior to this one required a 150-mile daily commute - amazing views of the Everglades, but it was a long commute. 
Snake Road - Big Cypress
And while my job was 8-5 the day ended up being 6:30-6:30 (or later, depending if there was an accident).  I went against traffic, so my 75-miles in an hour and a half was sometimes quicker than people’s 10-mile commute in traffic.  Regardless of the distance, it was the time that was taken away from me.  Moving forward I vowed I would stay with the job (as I loved teaching the kids) until I found something I truly, truly loved.  After three long years of searching I found my current position, a dietitian at a diabetes education center, 5 miles from home.  I thought what could be better?  Teaching about diabetes?  Close to home?  I’m in!  In my first year at my job I learned more than I could have ever imagined – insulin to carb ratios, insulin sensitivity factors, and that old notion of three meals/day, three snacks/day was based on an older insulin not often used anymore!  It truly was and has been an amazing opportunity and experience.  But with the good comes the bad.  And shortly after starting, that short commute didn’t really matter.  I was leaving so late there was no traffic to speak of.  My normal 8-hour workday was back to 10 and 12 hour days.  I love teaching about diabetes and how to manage it through diet and exercise.  I had a patient the other day who attended our diabetes class ~2 months ago.  His A1c at the time was 8.8% (well above goal) and upon his return to see me one on one, his A1c was down to 7.0%.  I asked him what he did to help improve (as medications had been removed and not added per his chart).  He said, “I followed what you and Lory (the nurse educator) told me to do!”  That my friends, that is what is rewarding.  He literally made my day!
Year 1
Teaching about diabetes is what I know I love.  There’s nothing better than helping a person count their carbs and match their insulin to what it is they’re eating to adjust a dose.  Maybe I’m a numbers geek?  Science nerd?  Not sure.  But what I do know is that I do not love teaching a person with a sole diagnosis of “obesity”.  Sure I understand that within diabetes the weight loss talk comes up.  How can it not?  If a person does lose weight it only helps their insulin work that much better.  But I know what my strengths are and teaching/coaching/being a cheerleader to help people lose weight is not my forte.  I had a patient come in the other day and stated that she gained 80 pounds in one year and there was nothing medically wrong with her (as she had everything checked out, thyroid, etc.) and she was asking me why she gained weight.  Um, I don’t know?  I feel helpless at times in talking to the patients and ultimately feel that I’m not helping them.  Food is so much more than just the science behind it.  I should’ve been taught more psychology in my college years in order to be able to better assist patients.  Sure I’ve gained knowledge over the years and sure my yoga background helps me to teach them to be mindful.   But at the end of the day, I haven’t been coming to work happy anymore.  And that my friends, is critical (in anyone’s job), to find what you love and love what you do!
Year 2
And so I move to the next chapter in my career.  I will be doing group nutrition education at various events all around South Florida.  I will be teaching about prevention mainly and there will be some pilot type programs that are geared towards some of the most common disease states within nutrition – diabetes, heart disease, and yes, weight management.  I think the thing that excites me the most is actually being able to reach a LOT of people all at once.  Teaching one on one can be rewarding (do not get me wrong…I will miss that to a certain extent). but it can also be taxing when you repeat the same thing over and over.  Group education with the premise of prevention…yes, I get excited just thinking about it.  Nutrition dork?  Maybe just a little too extreme when it comes to nutrition?  I prefer to think of it as being passionate – passionate about helping people to be healthy.  Isn’t that what you’d want from a dietitian??

So as my time winds down,  I started to reflect on my patients and what they’ve taught me  over these past three years.  A few stood out and here’s a few ditties that I pass on to you:

Working where I work, we get many international patients.  Patients from all over, i.e. Venezuela, Trinidad, Colombia, Brazil, etc., come to the United States for their care.  Pause just a moment and think about that for a minute – how lucky are we to live where we do have access to progressive thinking, state of the art healthcare?  (I will not get political in this post as to the state of insurance with healthcare…just keep thinking that we have access where many others do not).  There really were too many to recount.  The international patients were something special.  Appreciative of everything we could teach them in order to improve their health upon returning back to their country. 

The marathon runner/yogi. I’ll never forget the first day we were doing a program that she was attending.  Her continuous glucose monitor (CGM) was buzzing that she was “low”.  I nudged my nurse educator and we looked at each other communicating without speaking, “should we do something?”  It was in that moment I was taught a valuable lesson - patients know their bodies better than anybody else.  She immediately took out a cracker and kept watching her CGM – it was her way to nudge the blood sugar in the right direction, not to over treat, but simply to steer it in the right direction.  Sugar surfing at its finest.  She’s one of those patients that already knows so much, I often wondered if I was ever teaching her something or was she the one really teaching me?  Learn from others and look around, there’s always something new to learn. 

I used these measuring cups for every session I taught patients.  They were my special gift.  I received them from a kid with Type 1 diabetes that used these cups on repeat.  He wanted other kids to not have to go through what he went through and help transitioning to “counting carbs” to be as easy as possible.  He donated a whole box of these measuring cups for us (the nurse educator and myself) to pass out to newly diagnosed kids with Type 1.  Read the note.  You’ll see how special a kid he was.

This particular patient was sugar surfing before she knew she was sugar surfing.  We do a 4-day intensive program with patients in teaching them how to manage their diabetes.  Teaching them all the key concepts about real life situations and how to manage their diabetes, i.e. insulin adjustment guidelines, how to check their basal, etc.  This patient came in pretty much on the brink of giving up (as she described) because all of her doctors had told her that what she was doing wasn’t “right”.  The truth?  She was doing exactly what we were going to teach her to do – manage her diabetes, sugar surf, and make in-the-moment decisions about how to better control her diabetes.  She gained the confidence to know that she was in fact managing her diabetes and doing it to the best of her ability.  She has since communicated to us that through the use of the CGM and using multiple daily injections (versus a pump) her last A1c was as low as it’s ever been (without having hypoglycemic episodes).  She was writing to thank us.  Giving patients the tools to better manage their diabetes, yeah, that’s the rewarding part.

The local grocery store here in Miami has a program to give some medications free of charge and with others at a minimal cost.  Think that’s not a big deal?  For many of my patients it’s a REALLY big deal.  I had this one particular patient that kept continuously calling me in regards to her low blood sugar levels.  After various probes, I finally realized what was going on.  Her medication (for her DM) could induce lows as it was working for 24-hours.  This patient only ate once/day as she didn’t have enough food to have more meals than just one.  BINGO.  Her lows were due to lack of food access.  I found a food program here locally that the patient was able to get one free hot meal/day due to her age.   I taught her how to use the “Buy One Get One Free” at the local supermarket in order to get more food for the money that she did have (so she could have food for the month).  I was teaching her smart shopping and showing her ways to extend the money that she did have.  And at the end of the day, I taught her not to take her medicine if she wasn’t going to eat.  This patient taught me that it’s really easy to tell someone what to eat, but at the end of the day what do they really have access to in order to make that happen?  Compassion and empathy are key.
I wish I could give ALL the needy patients free food!
To all the kids with Type 1 DM – you are amazing, resilient, and capable beyond your means – you CAN do anything you want.  For whatever reason your own body decided to attack it’s beta cells so your pancreas doesn’t work anymore, but that should NOT stop you from doing anything your little hearts desire.  In one of those 4-day programs this one particular kid was thanking his parents for buying him his supplies.  What 12-year old has to think about where he is going to get his supplies from?  And yet he was here thanking his parents for being selfless and giving him what he needed before buying things for themselves.  These kids, surprise me every time.  Sometimes the kids would call us super heroes, when in reality they are the real heroes.  In case you're wondering, I was Super Girl.

In addition to the international patients, I receive what are termed VIP patients.  While I should preface and say that to me ALL patients are VIP, these particular patients are deemed to be a little more important (whether it’s their financial contribution to the university or whether they truly are famous).  There are some that come in and demand to be seen yesterday, when my schedule is booked for the next three months.  And then there are some that don’t want a big fuss at all made about their VIP status.  I think what the VIP patients have taught me is that no matter what your background might be or where you might progress to be, always remain humble.  Fame and fortune shouldn’t make you think you’re any more important than someone else.  We all need to be educated and helped at some point.

Last but certainly not least, my co-worker.  We started within in a few months of each other.  Who would’ve known that we would get along as well as we did?  Luck of the draw?  Not sure, but what I do know is that I’m beyond grateful for having met Lory.  I describe her as THE best nurse educator around.  She’s been given the nickname, “Flo” and “Wonder Woman” because she is just that, always going above and beyond in helping patients in their care.  It’s hard to put into words just what Lory means to me, but I know that I am forever changed having met Lory.  I have had other great co-workers (don’t go getting jealous out there Jill or Lance!) but when you have just each other to rely on, we were truly lucky to have had each other.  So glad you were my co-worker, but beyond that, I'm truly blessed to call you my friend.
I am truly grateful for these past three years and all that I’ve learned.  As I said, I’ve felt in these last few months that it’s time for me to move on.  Sometimes people look at change and are fearful.  For me, I’m hopeful of what’s to come and look forward to all the opportunities that lie ahead!

Sunday, June 4, 2017

A Little Bit of This and A Little Bit of That

A Little Bit of This and A Little Bit of That

I just got finished in the kitchen, doing my meal prep for the week.  I take 2-3 hours on Sunday morning and devote to cutting vegetables for the week, making sauces to expedite cooking time during the week, and even a little baking.  Today’s bread was an epic fail.  I followed the instructions to a tee – the only thing I can think of is something with the humidity in the air affected how it turned out.  The bread did rise as it said it would in the book.  I took a peek while it was baking and it was completely sunken in.  So not really sure, but I’m blaming it on the weather.  Yesterday it rained off and on ALL day.  Today it is cloudy and humid as all get out and there are supposed to be showers again.  So, I’m not going to get mad about it, I’m just going to have to keep trying.  Each week (time permitting) I’m trying a new recipe from Bread Illustrated ).  This is what I’m using as my stress relief/downtime which normally ends up yielding good results.  As I said, not gonna get mad, just gotta forget about it and try a new recipe (not sure I’ll repeat this one since it was such an epic fail…maybe in the future).
These were not the epic fail - these were Butter Fan Rolls from last week.  Luckily bread freezes!
Last week I had an 11-year old patient recently diagnosed with Type 2 diabetes (DM).  I’ll repeat that again so it can sink in what I just said.  11-year old patient diagnosed with Type 2 DM.  For anyone that doesn’t think we have a problem on our hands, this one patient alone should demonstrate we have a problem.  11 years old, 225 pounds, and knows nothing other than junk food and soda.  Houston we have a problem, a HUGE problem (no pun intended). This is one of many – there are others out there.  Whether they are about to be diagnosed or are walking around without knowing they have it, they’re about to have a rude awakening.  We have to start making healthy changes and start them when they are young.   Many people don’t act on changes to their diet until they are forced to do so – there’s never really been a push for prevention.  The irony is that most of the chronic diseases that we are seeing surface can be prevented through diet and exercise.  Diabetes is one of those said diseases.  While there are genetic risk factors associated with Type 2 DM, there are many studies that prove by making changes in diet and exercise it will help offset some of the risk.  Here are two articles I just recently was reading that talked about “reversing DM”.  And I should make mention that one does not “reverse DM” rather one controls their DM.  Once DM surfaces, it is there to stay.  Our aim is to control DM (and it can be), but it doesn’t just “reverse” as is common language used and leads people astray in thinking it will “disappear”.
A1c - the average blood sugar over 3 months - here shows a diagnosis of diabetes with a 6.6%.  After diet and exercise intervention, the patient's A1c decreased to 6.2%, a level showing control and now prediabetes.

A recent study suggested to have carbohydrate-rich meals earlier in the day.  They compared men with prediabetes having the carb-rich meals early (by 1:30 pm) and then a high-fat meal later on versus men having a fat-rich meal early and then the carb-rich meal later on.  What they found?  Glucose tolerance,  the body’s ability to handle carbs, gets worse as the day progresses.                                                                                                                                                           Sci. Re.. 2017 doi:10.1038/srep44170

In general I tell my patients to aim to reduce the load of carbs at meals – I don’t believe people at times have any idea of how many carbs they are consuming at any one meal.  A bowl of Raisin Bran (a bowl, not just a cup, what people are actually eating) could average around 135g of carbs.  A male should have only 45-60g of carbs/meal, so yes, I’m looking at you Raisin Bran – thought to be healthy when in fact it’s not!  We need to raise carb awareness in people and in general aim to reduce the load throughout the day (and not just at night) in people with prediabetes.  Both the quality and the quantity of the carbs matter when it comes to eating healthy.
In case you didn't believe Raisin Bran had that many carbs in what would be a bowl (some people might even be eating more!)
The other study looked at strength training.  The trial was called the Resist Diabetes trial.  They provided strength training for three months, twice a week, 12 supervised exercises for 8-12 repetitions each. They were followed up with 6 months of encouragement, followed by six months on their own.  After the 15 months, 30% of the participants had levels indicating their blood sugar levels were in control (or as the article states, “they no longer had prediabetes”)                             PLoS ONE 2017 doi:10.1371/journal/pone.0172610e

The bottom line?  If you’re not doing strength training, get started NOW.  People lose muscle as they age.  Building muscle helps insulin become more sensitized, meaning it works more efficiently.  And building muscle helps glucose uptake, so not as much insulin is even needed to begin with.  Strength training is a win-win all around.  Get started now.

Here are other key tips I tell all my patients – you choose what you need to work on – but consistency is also important:

-Lose weight (or not gain) extra pounds.  This is the obvious one and doctors tell their patients this, but the truth is through changes with diet and exercise and less focusing on the number on the scale, they will begin to lose weight.

-Shoot for at least 30 minutes of brisk walking or other aerobic exercise.  This sitting all day thing, it’s killing us.  Get up and move!

-Limit white flour, potatoes, and sweets – aim for whole grains and keep desserts to actual celebrations (not every day!)

-Eliminate any and ALL sugary beverages.  Unless you are an athlete and actually need that sports recovery drink, NO sweetened beverages.  Start thinking about your morning cup of joe – NO added sugar, period.

-Increase your non-starchy vegetables – broccoli, green leafy vegetables, peppers, onions, carrots, etc – we do NOT eat enough of this and we need to do better.  The FIBER plays a critical role in our body.  Everyone might know fiber helps them go to the bathroom, but it also helps lower blood sugar levels, lower blood pressure, lower cholesterol, and more recently been shown to help people lose weight.  Fiber – get it from whole foods.

Remember, the good news is that you can reduce your risk of diabetes.  Make changes in your diet and exercise, today! 

My cookbook obsession continues.  I mean did we expect anything less?  My latest acquisition is - Salt, Fat, Acid, Heat.  I’m excited to delve further into this book as each one of these elements plays an essential role in cooking.  I read the book by Michael Pollan, Cooked, a few years back and feel I need to learn more.  If I could master just these four elements —Salt, which enhances flavor; Fat, which delivers flavor and generates texture; Acid, which balances flavor; and Heat, which ultimately determines the texture of food— anything I cook will be delicious, minus user error, but you know what I mean.  I’ll at least have the theory.  And then comes the practice, because practice makes perfect.  Now to decide which section I’ll start with first…

I’m always looking for inspirational quotes and pictures to post for my Wellness Wednesday on the internet.  There are a lot that depending on the situation I’m going through will speak to me.  I saw a shirt a person was wearing the other day that said, “Calm to Crazy”.  I immediately thought of yoga and that by practicing yoga it helps me go from crazy to calm, so maybe we should make a shirt for that instead?!
Yoga has always been something that helps me get literally grounded and brings me back to my breath.  I feel if I can control my breath than I can control what’s going on around me (or at least accept what will be).  Lately I’ve felt that my breath is unsteady, and at times short and shallow – and while this may be due to certain circumstances lately, it’s my gentle reminder to stay true to my yoga and simply practice, aiming for consistency.  There are going to be bumpy roads and there are going to be moments in life that seem as if they are too much to handle.  The truth?  More reason to practice and tap into my breath control – plug in and make sure I am in balance and aligned so that I am able to go with the flow.  The more I’m able to control my breath, the more I’m able to control what’s going on around me.  Practice and all is coming.

Last but not least, my latest obsession, aka, what food I’m eating on repeat.  It depends on the day and the timing of my meals, but I’ll eat this ricotta cheese and tomato together as a snack as is (with lots of herbs mixed in for added flavor, although it tastes just fine without).  If my day is tending towards a long day with dinner later at night, I will have the same snack, only this time with crackers included – so think carbs, protein, and some healthy fat – all in order to sustain me until I do get home for dinner.  Simple and delish.  Eating healthy doesn’t have to be complicated.  Until next time…